Resident Survival Guide

Under patient lists, there is a folder (at each campus) titled, “Anesthesia” with a “CIV/GEN Anesthesia Follow Up” subfolder.  This is where you will find or can place any patient that requires follow up.  Note that this folder can be used for ANY patient in the hospital requiring follow up (eg. consult). 

Your staff may be unaware as to how to get a patient onto this list.  Everything in EPIC is driven by orders including the ability to place a patient on a list. 

For example, patient Bryce Harper is in the OR.  The attending staff wants this patient observed in the PACU.

How does the attending (or you) put this patient on the list?  As mentioned, we need an order.  A “quick” way to accomplish this is to use “Quick List”.  These lists were designed so that you don’t have to search for a specific order. 

Find the patient on the OR status board and go to the Intraprocedure workspace.  Go to “Orders”

Navigate to “Quick List”

We have created 5 of these lists which are self-explanatory.

In the “Postprocedure-Adult” Quick List, you will see the order for “Anesthesia Follow Up”.  Highlight and sign the order.

Select the context (or “ +Create New Context ”) to which this order is going to apply and “Accept”.

NB.  For some orders, you will be asked to assign a phase of care.  At time of writing, the “follow up order” is automatically being “signed and held”, meaning the RN will release it.  For orders that are relevant to nurses, holding an order until reviewed is important.  For this particular order, the relevance is for the MD.  Therefore, if you want to see this patient on the list right away, you need to manually release it.  Click the “Signed & Held” tab and you will see the order.

Click the link to release the order.

You will be asked which order you want to release.  In this example, there is only one.  Click the appropriate box and “ release ” the order.

Bryce Harper is now on the Follow Up list.

When the patient no longer requires your involvement, click “Complete” under the “Consult and Follow-up” tab and the patient will fall off this list.

While the patient is in the PACU, active orders are restricted to the “Anesthesia PACU Post Op” and “APS orders”, both of which would be placed by the team in the OR.  When completed in the OR, these orders are “Signed & Held” as the RN wants to review before releasing.  The RN will release once the patient arrives in the PACU.

Below is an example of PACU orders.

You are called by the PACU RN as Tylenol was not ordered and the patient is very uncomfortable. 

You decide you will increase the hydromorphone and will be happy to order the Tylenol.  You know Tylenol exists on the PACU order set.  However, in EPIC, you can’t bring up the existing order set for modification.

Under “Active” Orders, you see the hydromorphone.  You can easily adjust the dose by selecing “modify”.

For Tylenol, we will make use of the Quick List again.  Review the contents of the order once selected.  Some of them are defaulting to incorrect dosing and are easily modified.  This will be corrected in the near future.

You should familiarize yourself with the contents of the quick lists.  They will be very helpful to you.  The “ CVS Drugs-PACU ” quick list contains a large number of vasoactive drugs.  The “ Acute Pain Service ” Quick list will quickly allow you to modify APS orders. 

If you are really stuck trying to find a particular drug to order, either via the traditional “Manage Orders” or quick lists and you know the drug can be found in an “Order set”, then go to that order set.  As an example, you know that you can order a CBC through the “Anesthesia PACU Post Op” order set and can’t seem to find it any other way.  The issue with order sets is that there are often many pre-selected orders by default. 

Bring up the PACU order set.  The first thing you need to do is to “ Clear ALL Orders ”.  This will eliminate anything in the order set that is pre-selected by default. 

Select the CBC and sign the order

If a patient remains under our care in the PACU, it is our responsibility to write progress notes.

There are various ways to find your patient.  Regardless of how you get to the patient, you need to be able to navigate so you can draft your note.

Option 1: Using the Status Board

Double click on the patient.  As the patient is in the PACU, you will be taken to the Postprocedure navigator.  This is where you would normally complete documentation when you first arrive in the PACU after a procedure.  You won’t be doing anything in this navigator although it provides you with the ability to get to the “ Notes ”.  Click on “Notes”

You have two options

If you click “New Note”, you will be presented with a blank slate.

Make sure to identify the note type and service.  This will make the note easier to find later on through filtering.

If you click, “Create in Notewriter”, you will be presented with the following:

Select Progress Notes

We want the Postop Eval IP

You will bring up a basic template that includes the ability to perform a physical exam and document a plan.  It may or may not be suitable but can be used as a starting point.  Free texting within the note is also possible.  This note will be optimized at a later date with input from residents. (NB: notice the “ PACU Normal ” macro)

Option 2: Using the Patient List

or the Patient List.

Right click on any list to favourite it so it easier to find.

Highlight the patient and click on the “ Rounding/Other Consult ” tab. You will be taken to the “Consult + Rounding” navigator

Over on the right, you see the “Progress Notes”.  Use the drop down to select the Postop Eval note. (You can also create a speed button so you don’t have to use the pull down).   You will have the option of selecting either one of the options described above.

Please refer to the extensive documentation on the WIKI. (wiki.med.uottawa.ca) or as of this writing, the Anesthesia Learning Home Dashboard.  Familiarize yourself with the different scenarios that may play out:

1.       Routine call for epidural

2.       Labouring patient with epidural requiring a semi urgent C-Section

3.       Labouring patient with/without epidural requiring a STAT C-Section (Code 333)

All documentation for labour can be done on a WOW (workstation on wheels) located in every L&D room, any computer in the hospital or your own personal laptop.

**There is a significant change in workflow in L&D** .  You are now required to sign out drugs from the Omnicell against the patient’s name.  The drugs include:

1.       Two 10 ml syringes of Ropivacine 0.1% + Fentanyl 3 mcg/cc

2.       One bag of Ropivacaine 0.08% + Fentanyl 2 mcg/cc

Before documenting the Epidural Px, it is NECESSARY that you complete the “Birthing Unit: Epidural Analgesic” order set.  Otherwise, you will not be able to document the administration of the Rop 0.1% + 3 mcg/ml Fentanyl.

If you have access to a computer before proceeding to L&D, you can complete the above order set.  Unfortunately, you cannot use your phone or iPad to complete an “Order Set”.  It is only possible to order items one at a time.  This is not practical for the birthing unit as the order set contains many defaulted nursing orders.

Please refer to the extensive documentation on the WIKI or Anesthesia Provider Home Dashboard.

iPads are not useful anymore.  We now have Microsoft Surface Devices but these will be locked away.  Your only choice is to use your personal laptop or WOW’s on the floor.

**any patient admitted to the APS before 04:00 on Saturday will continue to have their daily progress documented in ACUPAM.  However, all orders will have been cutover to EPIC.  Having said that, depending on the weekend workload, we may elect to cut over all progress notes to EPIC as well.  You will see documentation in the General Notes stating that meds have been cutover.  Technically, any patient admitted to APS before 04:00 can have their billing completed in ACUPAM.

For any patient admitted to the service after 04:00 on June 1, all documentation will be done in EPIC.  You will be presented with a billing option when you sign your daily progress note.  Click on the appropriate option.  If you are being called to see a patient, this would be considered a “Requested APS Visit” and a premium may also be applicable in this situation.   Please the doc on either platform as previously discussed.  Other information will also be requested from you.

As with ACUPAM, we are trying to do all billing electronically.  However, at initial GoLIve, we need to collect stickers and affix to our billing sheets to ensure that EPIC captures the billing correctly.  This could be a challenge.  Again, info can be found on the various platforms (look under Q &A) but I have included below.  You may be able to do it at a WOW.  If not, you will have to ask the ward clerk.  We need a specific label type for billing information.  If you can’t print a label, then you need to collect the following information on the patient.

MRN

Name

Date of Birth

Gender

Date of Admission

OHIP number (including version code)

I will get back to you on where to find the OHIP number

When asked to perform a Procedure on the floor, the workflow below applies.

Locate the patient using patient lists. Double click on the patient.

You are presented with the following list of procedures.  Select the most relevant. 

As an example, let us assume you are called to a code blue and need to intubate the patient.  Select “ Intubation ”

You will be presented with a screen that looks similar to what you would see intraoperatively but there is no grid for meds/graph for vitals.

As in the OR, use the events to mark the timeline and reminders to complete the requisite information.

If you want to write a note, click on the “Memo” button.  Some of you have already built and shared some nice smart phrases.  Having said that, a lot of what you will want to say will be included in the body of the procedure note that generated by the system.  I would recommend looking at the finished note before you start to add too much information which could be redundant.

Please refer to the extensive documentation on the WIKI or Anesthesia Provider Home Dashboard.